129,498 research outputs found

    Construction of a Versatile Ultra-Low Temperature Scanning Tunneling Microscope

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    We constructed a dilution-refrigerator (DR) based ultra-low temperature scanning tunneling microscope (ULT-STM) which works at temperatures down to 30 mK, in magnetic fields up to 6 T and in ultrahigh vacuum (UHV). Besides these extreme operation conditions, this STM has several unique features not available in other DR based ULT-STMs. One can load STM tips as well as samples with clean surfaces prepared in a UHV environment to an STM head keeping low temperature and UHV conditions. After then, the system can be cooled back to near the base temperature within 3 hours. Due to these capabilities, it has a variety of applications not only for cleavable materials but also for almost all conducting materials. The present ULT-STM has also an exceptionally high stability in the presence of magnetic field and even during field sweep. We describe details of its design, performance and applications for low temperature physics.Comment: 6 pages, 9 figures. accepted for publication in Rev. Sci. Instru

    The effect of road and sea transport on inflammatory, adrenocortical, metabolic and behavioural responses of weanling heifers

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    peer-reviewedThe objective was to investigate the effect of transport on inflammatory, adrenocortical, metabolic and behavioural responses of weanling heifers transported from Ireland to Spain. Background: At the end of the grazing season, 60 Charolais × beef heifers (mean live weight 245, s.e. 4.3 kg and mean weaning age 219, s.e. 4.9 days) were abruptly weaned from their dams on day 0. The animals were assigned by live weight to two treatments, transport (T) (n = 40) (mean 246, s.e. 5.4 kg) and control (C) (n = 20) (mean 247, s.e. 7.2 kg) on day 0. The T animals were transported from Ireland to France on a roll-on roll-off ferry at a stocking density of 0.93 m2/animal and then by road for 9 h to a French lairage while C animals remained in Ireland and were not transported. On arrival at the French lairage (d 2), 20 T animals were unloaded (ULT) and rested for 12 h in the French lairage and 20 animals rested (RT) on the transporter. All animals had access to hay and water. After the rest period, the ULT animals were re-loaded. The subsequent journey by road from France to Spain was 9 h travel, 7 h rest (on the transporter) and a further 7 h travel by road. All T animals were blood sampled prior to transport (day (d) 0; baseline), on arrival in the French lairage (d 2), after 12 h rest in the French lairage (d 2), on arrival at the feedlot in Spain (d 4) and on d 6, d 8, d 10 and d 34. Control animals were blood sampled at the same times as T animals. Results: ULT and RT animals had lower (P 0.05) in plasma protein concentration between RT and ULT animals from day 2 to d 34. Plasma concentrations of urea were higher (P < 0.05) in RT animals from d 2 to d 34 compared with C animals. RT and ULT animals had lower (P < 0.05) non-esterified fatty acid (NEFA) and βeta-hydroxy-butyrate (ßHB) concentrations on d 10 and d 34 compared with d 0. Conclusion: It is concluded that, within the conditions of the present study, the performance of the animals that remained on the transporter during the 12 h lairage period in France was not different post-transport from the transported animals that were unloaded and lairaged in France

    Does the initiation of urate lowering treatment during an acute gout attack prolong the current episode and precipitate recurrent attacks: a systematic literature review

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    Objectives: To systematically review the literature on effect of initiating urate lowering treatment (ULT) during an acute attack of gout on duration of index attack and persistence on ULT. Methods: OVID (MEDLINE), EMBASE and AMED were searched to identify randomized controlled trials (RCTs) of ULT initiation during acute gout attack published in English language. Two reviewers appraised the study quality and extracted data independently. Standardised mean difference (SMD) and relative risk (RR) were used to pool continuous and categorical data. Meta-analysis was carried out using STATA v14. Results: 537 studies were selected. 487 titles and abstracts were reviewed after removing duplicates. Three RCTs were identified. There was evidence from two high quality studies that early initiation of allopurinol did not increase pain severity at days 10 to 15 (SMDpooled (95%CI) 0.18(-0.58, 0.93)). Data from three studies suggested that initiation of ULT during an acute attack of gout did not associate with drop-outs (RRpooled (95%CI) 1.16(0.58, 2.31)). Conclusion: There is moderate-quality evidence that the initiation of ULT during an acute attack of gout does not increase pain severity and risk of ULT discontinuation. Larger studies are required to confirm these findings so that patients with acute gout can be initiated on ULT with confidence

    Long-term persistence and adherence on urate-lowering treatment can be maintained in primary care-5-year follow-up of a proof-of-concept study

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    Objectives: To evaluate the persistence and adherence on urate-lowering treatment (ULT) in primary care 5 years after an initial nurse-led treatment of gout. Methods: One hundred gout patients initiated on up-titrated ULT between March and July 2010 were sent a questionnaire that elicited information on current ULT, reasons for discontinuation of ULT if applicable, medication adherence and generic and disease-specific quality-of-life measures in 2015. They were invited for one visit at which height and weight were measured and blood was collected for serum uric acid measurement. Results: Seventy-five patients, mean age 68.13 years ( s . d . 10.07) and disease duration 19.44 years ( s . d . 13), returned completed questionnaires. The 5-year persistence on ULT was 90.7% (95% CI 81.4, 91.6) and 85.3% of responders self-reported taking ULT ⩾6 days/week. Of the 65 patients who attended the study visit, the mean serum uric acid was 292.8 μmol/l ( s . d . 97.2). Conclusion: An initial treatment that includes individualized patient education and involvement in treatment decisions results in excellent adherence and persistence on ULT >4 years after the responsibility of treatment is taken over by the patient's general practitioner, suggesting that this model of gout management should be widely adopted

    Singular cardinals and strong extenders

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    We investigate the circumstances under which there exist a singular cardinal μ\mu and a short (κ,μ)(\kappa, \mu)-extender EE witnessing "κ\kappa is μ\mu-strong", such that μ\mu is singular in \Ult(V, E).Comment: 8 page

    Personalized medicine of urate-lowering therapy for gout

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    Gout is a common and complex form of arthritis that is characterised with hyperuricaemia. It is required urate-lowering therapy (ULT) for lifelong management. ULT includes decreasing uric acid product in serum, increasing renal urate excretion and promoting uric acid to allantoin for excretion. Whole genome association studies in gout identified more than 40 genetic loci that influenced the serum uric acid levels. Most associated genes were found to affect renal urate excretion. Pharmacogenetics and pharmacogenomics approaches on ULT had revealed several genes that underlined the effectiveness and the adverse events of medications for gout. Together with the researches on epigenetic factors such as DNA methylations, miRNAs; and the discovery of environmental factors such as microbiota and metabolites, the current progress provides the opportunities for personalized management of ULT for treating hyperuricaemia and gout

    Modifiable Barriers to Optimal Outcomes in Gout Management

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    Improving patient outcomes in chronic disease is of critical importance to the future of health care. Gout, affecting 4% of the US population, is a highly treatable chronic disease from which patients experience unnecessarily suboptimal outcomes. In this dissertation, I demonstrate how interrelated patient and provider factors affect patient outcomes in gout. First, I describe how only 14% of gout patients know their serum urate (SU) goal for urate lowering therapy (ULT) despite otherwise being knowledgeable about gout and its treatment. I then demonstrate the importance of multiple patient and provider factors in achieving SU goal. Specifically, I demonstrate that ULT medication adherence, ULT dose escalation and a high ULT starting dose are associated with SU goal attainment. However, I show that a high starting dose is also associated with worse SU goal attainment through its negative impact on medication adherence. These findings demonstrate not only the importance of patient and provider behaviors in achieving optimal outcomes, but also their interrelated nature. Finally, I report that there is no evidence from a large national study that ULT dose escalation reduces mortality among gout patients. In further analysis, I demonstrate that the lack of evidence could be due to inadequate final ULT doses observed even among patients receiving dose escalation. Importantly, the patient and provider factors I identify in this work are all modifiable. Future interventions should address the broad care context outlined in the Chronic Care Model to target these interrelated, modifiable factors and achieve optimal outcomes in gout

    The PREVENT Study: Preventing hospital admissions attributable to gout

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    BackgroundGout is the most common form of inflammatory arthritis, affecting 1 in 40 people in the UK. Despite highly effective treatments, hospital admissions for gout flares have doubled in England over the last 20 years. Many of these admissions may have been prevented if optimal gout management had been delivered to patients.Objectives1. Describe the epidemiology of gout management in primary and secondary care in the UK.2. Develop an intervention package for implementation during hospitalisations for gout flares, with the aim of improving care and reducing hospitalisations.3. Implement and evaluate this intervention in people hospitalised for gout.MethodsI used population-level health datasets (CPRD, OpenSAFELY, NHS Digital Hospital Episode Statistics) to evaluate outcomes for people with incident gout diagnoses over a 20-year period. I used multivariable regression and survival modelling to analyse factors associated with outcomes, including: i) initiation of urate-lowering therapies (ULT); ii) attainment of serum urate targets; and iii) hospitalisations for gout flares.With extensive stakeholder input, I developed an evidence-based intervention package to optimise hospital gout care. This incorporated the findings of a systematic literature review and process mapping of the admitted patient journey in a cohort of hospitalised gout patients. My intervention consisted of a care pathway, based upon British (BSR), European (EULAR) and American (ACR) gout management guidelines, which encouraged ULT initiation prior to discharge, followed by a nurse-led, post-discharge review to facilitate handover to primary care. I implemented this intervention in patients hospitalised for gout flares at King’s College Hospital over a 12-month period, and evaluated outcomes including ULT initiation, urate target attainment and re-admission rates.ResultsIn the UK, between 2004 and 2020, I showed that only 29% of patients with gout were initiated on ULT within 12 months of diagnosis, while only 36% attained urate targets. No significant improvements in these outcomes were observed after publication of updated BSR and EULAR gout management guidelines. Comorbidities, including chronic kidney disease, heart failure and obesity, associated with increased odds of ULT initiation but decreased odds of attaining urate targets. For patients who were diagnosed with gout during the COVID-19 pandemic, I showed that ULT initiation improved modestly, relative to before the pandemic, while urate target attainment trends were similar. Underlying these trends was a 31% decrease in incident gout diagnoses in England during the first year of the pandemic.Using linked primary and secondary care data, I showed that the risk of hospitalisations for gout flares is greatest within the first 6 months after diagnosis. ULT initiation is associated with more hospitalisations for flares within the first 6 months of diagnosis, but a reduced risk of hospitalisations beyond 12 months; particularly when urate targets are attained.After process mapping the admitted patient journey and systematically appraising the evidence base, I developed and implemented a multi-faceted intervention at King’s College Hospital, with the aim of improving hospital gout care. Following implementation of this intervention, the proportion of hospitalised gout patients who initiated ULT increased from 49% to 92%; more patients achieved serum urate targets; and there were 38% fewer repeat hospitalisations for gout flares.ConclusionsAt a population level, ULT initiation and urate target attainment remain sub-optimal for people with gout in the UK, despite updated management guidelines. Initiation of ULT is associated with long-term reductions in hospitalisations for flares; however, only a minority of patients hospitalised for gout flares are initiated on ULT. After designing and implementing a strategy to optimise hospital gout care, over 90% of patients were initiated on ULT, urate target attainment improved, and repeat hospitalisations decreased. My findings suggest that improved primary-secondary care integration is essential if we are to reverse the epidemic of gout hospitalisations

    Collaborative Governance Dalam Pelayanan Perlindungan Anak Di Indonesia

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    Perlu dipahami bahwa anak sebagai generasi bangsa merupakan aset yang berharga. Kondisi saat ini adalah kasus anak yang merajalela memiliki pola traumatis yang dapat mempengaruhi terbentuknya karakter anak tersebut. Oleh karena itu, pemerintah harus fokus pada penanganan masalah sosial anak jika mereka menginginkan Indonesia memiliki generasi penerus bangsa yang dihormati. Kabupaten Tulungagung Provinsi Jawa Timur menjadi kabupaten pertama di Indonesia yang benar – benar serius dalam mengadvokasi permasalahan sosial anak. Tata kelola kolaboratif yang dilakukan dalam pelayana&nbsp; permasalahan sosial anak di Kabupaten Tulungagung diwujudkan dalam bentuk Unit Pelayanan Terpadu Perlindungan Sosial Anak Integratif (ULT PSAI) sebagai model layanan terintegrasi dalam mengadvokasi masalah sosial anak di Kabupaten Tulungagung. Tujuan dari penelitian ini adalah: 1) mengetahui peran Pemerintah Daerah dalam mengembangkan model pelayanan integratif untuk menangani kasus masalah sosial anak yang terjadi di Kabupaten Tulungagung; (2) mengetahui model sistem advokasi anak yang dilakukan oleh ULT PSAI, (3) mengidentifikasi keefektifan kegiatan ULT PSAI Kabupaten Tulungagung dalam mengadvokasi permasalahan sosial anak. Metode yang digunakan dalam penelitian ini adalah Participatory Action Research (PAR) melalui (FGD) dengan ULT PSAI, korban dan Organisasi Perangkat Daerah terkait untuk mendapatkan data. Data yang diperoleh kemudian diolah dan dianalisis secara deskriptif kualitatif. Artikel ini membahas: 1) pemerintah daerah dalam mengadvokasi masalah sosial anak melalui ULT PSAI adalah dengan melibatkan seluruh Organisasi Perangkat Daerah di Kabupaten Tulungagung sesuai dengan kompetensi dan permasalahan sosial yang dihadapi anak, 2 ) layanan primer), layanan sekunder (penjangkauan terhadap kelompok berisiko), layanan tersier (respon terhadap korban anak), 3) Keefektifan PSAI ULT dapat diidentifikasi dari jumlah dan jenis kasus masalah sosial yang ditangani anak. Melihat keefektifan model layanan ini dapat digunakan sebagai model percontohan untuk daerah lain di Indonesia
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